Current State of AIDS Epidemic in
Nigeria: Role of ARVs on PMTCT
Atiene Solomon SAGAY MD, FWACS, FRCOG (Lond)
Professor of Obstetrics and Gynaecology
Chairman, PMTCT National Task Team
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OUTLINE
• Introduction
• Adoption of Global e-MTCT Plan
• What Nigeria planned to do / Projections
• Achievements by end 2012
• What is the way forward?
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3
HIV positive persons: 3.1millionAnnual Births: ~6 millionHIV prevalence (ANC): 4.1% ( 2010)HIV+ pregnant women(annual): ~229,480
• 58% of pregnant women attend ANC at least once• 45% attend at least 4 times• 35% of births occur in health facilities• 39% deliveries by Skilled Birth Attendants • HIV+ Babies (annual) : 50,000 – 80,000
Introduction 1
BHPF 2013 Abuja
4
Introduction 2
• Nigeria has the 2nd highest burden of HIV globally• About 3.4m PLHIV ( spectrum 2012)• 270,000 new infections occurred in 2012
- Adults 210,000 - 58% Women- 42% Men
- Children 60,000 (Highest annual new cases globally)• Rate of MTCT in Nigeria - 30% ( modeling 2012)• 70% of HIV infection concentrated in 12 + 1 out of 36 states
of the country
• Nigeria accounts for about 30% global MTCT BHPF 2013 Abuja
Number of facilities offering PMTCT services nationally
419
533
670 675744
1,320
0
200
400
600
800
1000
1200
1400
2007 2008 2009 2010 2011 2012
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HIV Treatment / PMTCT in Plateau State
APIN
JUTH
SATELLITES SITES
PRIMARY HEALTH CARE FACILITIES
COMMUNITY25/11/2013 7BHPF 2013 Abuja
Score Board after nearly One Decade of
Implementation
Nigeria South Africa
HIV+ pregnant women: 210,000 210,000
Coverage of ARV/ART for PMTCT: 22% 88%
Estimated HIV incidence (modelled): 0.39% 1.68%
Contraceptive prevalence: 20% 62%
Unmet need for FP: 20% 14%
ANC at least 1 visit: 58% 92%
Median duration of BF: 19 m 16 m
MTCT rate in 2009: 32% 19%
New child infections 2009: 64,700 40,500
Sources: WHO Universal access report 2010, Nigeria DHS 2008, South Africa DHS 2003, UNAIDS analysis
BHPF 2013 Abuja 825/11/2013
Paediatric HIV Epidemic in Nigeria
• Flourishing on innocent little lives
• Entirely preventable
• We know what to do
• We know how to do it
• Stakeholders are willing and supportive
• .......Hope is not lost but where are the
actors?
25/11/2013 BHPF 2013 Abuja 9
Launch of the Global Plan 2011
Two Global Targets:
• Reduce new HIV infections among children by 90%
• Reduce number of AIDS related Maternal deaths by 50%
A 4-Point Plan:
• Frame it
• Advocate for it
• Do it
• Account for it
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Goal: "To eliminate new paediatric HIV infections and improve
maternal, newborn and child survival and health in the context of HIV."
Overall Targets
1. Reduce new paediatric HIV infections by 90%
2. Reduce mother-to-child transmission rate (MTCT) to <5%
Prong Targets and Indicators
Prong 1: 50% reduction in HIV incidence (+3 indicators)
Prong 2: Unmet FP to ZERO (+1
indicator)
Prong 3: Vertical transmission < 5% (<2%
around 6 weeks) (+9 indicators)
Prong 4: 90% reduction in HIV-related maternal and infant and child deaths (+4 indicators)
Nov. 2010 Geneva Consultation on EliminationNov. 2010 Geneva Consultation on Elimination
12BHPF 2013 Abuja25/11/2013
Towards Elimination of MTCT in Nigeria• Renewed Commitment for Elimination of MTCT
– Commitment to fully implement New Scale up (e-MTCT) Plan (2011-2015)
• Equity-focused strategic analysis of current program performance to identify
and overcome bottlenecks (routine program data, effectiveness study, etc..)
• Strengthened emphasis on Prongs 1&2 through better collaboration and
integration of SRH, MNCH and HIV programs.
– Programming for E-MTCT will not occur in isolation and calls us to get out of
our comfort (Prong 3&4) zone
• Sustained funding for cost-effective interventions to support elimination of
MTCT and contribute to maternal health and child survival.
• National leadership, States and LGA buy-in, accountability and ownership
(communities).
13BHPF 2013 Abuja25/11/2013
Nigeria: 2011-2015 e-MTCT Targets
• Reduce HIV incidence among women of reproductive age by 50% between 2011 and 2015
• Reduce unmet need for family planning by 100% between 2011 and 2015
• Reach 90% of HIV-positive women and infants with ART or ARV prophylaxis according to National PMTCT guidelines
BHPF 2013 Abuja 1525/11/2013
Number of new child HIV infections due to mother to
child transmission, by scenario, Nigeria
2010 – base scenario: 2009 programme coverage maintained through 2015
50_100_90 – intervention scenario: 50% reduction in HIV incidence, eliminate unmet
need for family planning, provide ARVs or ART to 90% of women in need
FMOH / UNAIDSBHPF 2013 Abuja 1625/11/2013
Number of new HIV infections among reproductive
age women, by scenario, Nigeria
2010 – base scenario: 2009 programme coverage maintained through 2015
50_100_90 – intervention scenario: 50% reduction in HIV incidence, eliminate unmet
need for family planning, provide ARVs or ART to 90% of women in need.
FMOH / UNAIDSBHPF 2013 Abuja 1725/11/2013
Number of women living with HIV giving birth
(women in need of PMTCT services), by scenario,
Nigeria
2010 – base scenario: 2009 programme coverage maintained through 2015
50_100 intervention scenario: 50% reduction in HIV incidence, eliminate unmet
need for family planning.
FMOH / UNAIDSBHPF 2013 Abuja 1825/11/2013
ARV coverage and regimen, intervention scenario, Nigeria
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Single dose nevirapine Dual ARV
Option A - maternal Option B - triple prophylaxis from 14 w eeks
Triple ART started before current pregnancy Triple ART started during current pregnancy
In this scenario the 2015 regimen and coverage will result in 8% transmission rate
Percent of women receiving ARV or ART by regimen, by
scenario, Nigeria
BHPF 2013 Abuja 1925/11/2013
MTCT transmission rate, Nigeria
0%
5%
10%
15%
20%
25%
30%
35%
40%
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Per
cen
t
MTCT rate - 2010 MTCT rate - interventions
2010 – base scenario: 2009 programme coverage maintained through 2015
50_100_90 – intervention scenario: 50% reduction in HIV incidence, eliminate unmet need for family
planning, provide ARVs or ART to 90% of women in need.
Estimated mother to child transmission rate (including
transmission during pregnancy, delivery and breastfeeding),
by scenario, Nigeria
FMOH / UNAIDSBHPF 2013 Abuja 2025/11/2013
E-MTCT in Nigeria: The Worry
• Progress in Nigeria is critical to eliminating new
HIV infections among children globally.
• Nearly all indicators assessed show stagnation
and suggest that Nigeria is facing significant
hurdles.
• Meeting the 2015 targets requires massive
effort.
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E-MTCT in Nigeria: On-going Efforts
• Government has taken a bold step to focus on
the 12+1 states with the highest burden of HIV,
which account for about 70% of new HIV
infections.
• In addition, it is rapidly scaling up service
delivery to stop new HIV infections among
children
• Govt. has embarked on an intensive state-
focused data-driven decentralization initiative.
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National Focus
• Saturation of PMTCT services in the 12+1 states with highest HIV/AIDS burden
• Improved Ownership and Coordination at State level • Intensive state-focused data-driven decentralization
initiative.• Increased involvement of the Organised Private
Sector and Private Health facilities • Strengthening MCH services and RH/HIV
integration • All PMTCT sites to provide EID services
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“Option B+” “Option B”
For programmatic and operational
reasons, particularly in generalized
epidemics, all pregnant and
breastfeeding women infected with
HIV should initiate ART as lifelong
treatment.
(conditional recommendation, low-
quality evidence)
For programmatic and operational
reasons, particularly in generalized
epidemics, all pregnant and
breastfeeding women infected with
HIV should initiate ART as lifelong
treatment.
(conditional recommendation, low-
quality evidence)
All pregnant and breastfeeding women infected with HIV should initiate triple ARVs (ART),
which should be maintained at least for the duration of mother-to-child transmission risk.
Women meeting treatment eligibility criteria should continue lifelong ART .
(strong recommendation, moderate-quality evidence)
In some countries, for women who
are not eligible for ART for their own
health, consideration can be given to
stopping the ARV regimen after the
period of mother-to-child
transmission risk has ceased.
(conditional recommendation, low-
quality evidence)
In some countries, for women who
are not eligible for ART for their own
health, consideration can be given to
stopping the ARV regimen after the
period of mother-to-child
transmission risk has ceased.
(conditional recommendation, low-
quality evidence)
2013 WHO Recommendations
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Rationale: Shift from Option A to B+ or B
Major issue now is not “when to start” or “what to start” but “whether to stop”Major issue now is not “when to start” or “what to start” but “whether to stop”
BENEFITS FOR MOTHER AND CHILD BENEFITS FOR PROGRAM DELIVERY &
PUBLIC HEALTH
Ensures all ART eligible women initiate
treatment
Reduction in number of steps along PMTCT
cascade
Prevents MTCT in future pregnancies Same regimen for all adults (including
pregnant women)
Potential health benefits of early ART for
non-eligible women
Simplification of services for all adults
Reduces potential risks from treatment
interruption
Simplification of messaging
Improves adherence with once daily, single
pill regimen
Protects against transmission in discordant
couples
Reduces sexual transmission of HIV Cost effective
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FIRST-LINE REGIMENS (PREFERRED ARV REGIMENS)
TARGET
POPULATION 2010 ART GUIDELINES 2013 ART GUIDELINES
STRENGTH &
QUALITY OF
EVIDENCE
HIV+ ARV-NAIVE
ADULTS
AZT or TDF + 3TC (or
FTC) + EFV or NVP
TDF + 3TC (or FTC) + EFV
(as fixed-dose combination)
Strong,
moderate-quality
evidence
HIV+ ARV-NAIVE
PREGNANT
WOMEN
AZT + 3TC + NVP or
EFV
HIV/TB
CO-INFECTION
AZT or TDF + 3TC (or
FTC) + EFV
HIV/HBV
CO-INFECTION
TDF + 3TC (or FTC) +
EFV
Summary of Changes in WHO Recommendations: What to Start in Adults
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Key research questions: Pregnant Women
ARV toxicity surveillance:• Safety of early, lifelong ART for pregnant and breastfeeding women?
• Maternal toxicity, pregnancy toxicity (stillbirth, low birth weight, prematurity,
birth defects) and infant toxicity?
Mother-to-child transmission and mother and child health impact:• Impact on overall HIV-free survival and and overall MTCT rate (at the end of
breastfeeding as well as at 6-weeks)?
• Impact on maternal morbidity and mortality, sexual transmission, and the long-
term success of first-line ART?
Adherence and retention: • Acceptability of ART to women, especially those who initiate lifelong ART before
they meet «adult eligibility» criteria»
• Adherence and retention rates for women with both low and high CD4?
• Health systems and community interventions needed to achieve high levels of
adherence and retention in setting of universal ART?
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STEPS TO HIV-FREE GENERATION IN NIGERIA
TasP
Combination Prevention
Family Planning
(LAPMs)
EIDOption
B+
HIV-free
Generation
Male
Involvement
Decentralization
: HIV/MCH/RHPrivate Sector
EngagementPrivate Sector
EngagementTask-Shifting
Paed
ART
Community engagement for participation and action25/11/2013
35BHPF 2013 Abuja
Conclusion
• Eliminating mother-to-child transmission of
HIV requires a solid foundation in community
partnership
• Although antiretroviral drugs (ARVS) alone
cannot achieve this goal, without ARVs there
will be very little movement
• The key is to address all strategies
concurrently
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Acknowledgements
• NASCP FMOH
• PMTCT National Task Team
• Dr. Nathan Shaffer and Members of all the WHO 2013 Consolidated GDGs
• FHI 360 for inviting me to make this presentation
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